What is their current living situation?*

Estimate How Much Care They Might Need*

What Type of Care is Needed? (Check all that apply)*

Light Meal Preparation

Light Laundry

Light Housekeeping

Companionship

Transportation to Appointments

Grocery Shopping

Errands

Bathing

Toileting

Medication Reminders

Respite Care

Hospice

How will care be paid for?*

Private Funds

Long-Term Care Insurance

Medicaid

Other - (VA Aid and Attendance, Reverse Mortgage, etc)

Many Senior In-Home Care services and products are not covered by insurance, Medicare, Medicaid or public assistance. Most individuals and families often need to pay "out-of-pocket" for some or all services requested. Are there other sources of financing available to you, such as Social Security benefits, VA benefits, or Private Funds?*